4 Integrated Care Increasing recognition that Medicaid enrollees have complex needs that cross systems. Care can be complicated or fragmented by the differing missions, funding and administrative procedures of these different systems. Treatment costs can be inflated by perverse incentives to provide more care than is necessary. Outcomes can be improved when care is integrated and coordinated; coordinated care helps avoid contraindications in treatment and duplicated or unnecessary treatment. Health care reform involves changes to care delivery, payment systems and measurement of health outcomes. 4

5 Integrated Care: ACOs and RCCOs Accountable Care Organizations (ACOs): Groups of providers that voluntarily assume responsibility for the care of a population of patients and share payer savings, if they meet quality and cost performance benchmarks. Also known as shared savings and accountable care collaborative programs. Regional Care Collaborative Organizations (RCCOs): In 2010, the Colorado Department of Health Care Policy and Financing issued a request for proposals for developing and implementing Regional Care Collaborative Organizations in seven geographic regions of the state. The aim of these organizations is to control healthcare costs and improve health outcomes for Medicaid members by improving coordination of care and establishing primary care medical homes for all enrollees. Since their implementation in January 2011, the seven RCCOs have enrolled thousands of Medicaid beneficiaries and dozens of primary care provider groups. The RCCOs receive funding based on their member enrollment. 5

6 What about the BHOs and MHCs? BHOs and individual MHCs are currently working with the RCCOs to provide specialty mental health services to RCCO members. In some cases, the MHCs are working as partners with the Federally Qualified Health Centers (FQHCs) and Rural Health Centers to meet members mental health needs and provide care coordination in a more integrated fashion. The Colorado Department of Healthcare Policy and Financing is expected to issue a RFP for the BHOs in This will be a transitional period of approximately two years, until the RCCOs fully phase in management of both behavioral health and medical benefits for Medicaid enrollees. System reform offers opportunities to reduce system fragmentation and redesign the Medicaid benefit e.g., include substance abuse disorders, TBI conditions, or other diagnoses that are now excluded. 6

7 What is Care Coordination? Care coordination refers to activities and interventions that attempt to reduce fragmentation and improve the quality of referrals and transitions. Integrated Care Coordination characteristics include: Ensuring that physical, behavioral, long-term care, social, and other services are continuous and comprehensive; and the service provider communicate with one another in order to effectively coordinate care. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies, Volume 7 Care Coordination

8 Case Management vs. Care Coordination Historically, case management programs rely on a medical model focused on the patient s health care needs only, while care coordination programs tend to use a broader social service model that considers the patient within a psychosocial context as well. Care coordination is often used interchangeably with referral or transition coordinator. Transitions from hospital care to home or community-based settings are especially important. Typically limited to essentially non-clinical yet logistical help including assuring timely and effective referrals, tracking and transitions, and transfer of patient information. 8

9 Who needs to be included in care coordination? Long-term care providers and single entry point agencies Primary care and specialty care medical providers Department of Human Services Department of Developmental Disabilities Other substance abuse treatment or behavioral health treatment providers Waiver service providers 9

11 How are members rights protected? The Care Coordinator will ensure that all communications with other providers are in accord with applicable Federal and State requirements related to the protection of individually identifiable health information. These requirements include those specifically identified in 45 CFR, parts 160 and 164, subparts A and E (HIPAA), to the extent that they are applicable. When there are questions about whether particular information can be exchanged, the Care Coordinator is directed to consult with the VO CO Contract Compliance Officer to resolve these questions prior to releasing the information. 11

12 Clinical Guidelines VO Colorado Partnerships develops, revises and/or adopts Treatment Guidelines from recognized sources and scientific bodies including professional organizations (e.g., APA) based on scientific evidence, best practice standards, and input from board certified physicians from appropriate specialties, practitioners, members, and community agencies. VO Colorado Partnerships disseminates its professional guidelines to practitioners who will have clients for whom the guidelines are indicated. VO Colorado Partnerships measures adherence to its guidelines and manages exceptions to guideline use through its existing quality audit procedures. VO Colorado Partnerships reviews and updates treatment guidelines every two years, or as necessary to reflect current knowledge about best treatment practices. 12

13 Where to find the clinical guidelines prv_clin_gd.htm ation.htm 13

14 What are Evidence-Based Practices? Practitioners seldom have as much evidence as they would like about the best clinical approach to use in any given clinical situation. To choose the optimal approach for each client, clinicians must draw on research, theory, practical experience, and a consideration of client perspectives. Evidence-based Practices: Approaches to prevention or treatment that are based in theory and have undergone scientific evaluation. "Evidence-based" stands in contrast to approaches that are based on tradition, convention, belief, or anecdotal evidence. Promising Practices: Science-based programs that showed at least some positive outcomes. 14

18 EBP Resources SAMHSA's National Registry of Evidence-based Programs and Practices (NREPP): NREPP is a searchable database of interventions for the prevention and treatment of mental health and substance use disorders. SAMHSA's Guide to Evidence-Based Practices (EBP) on the Web: This guide provides a list of Web sites with information about specific EBPs or reviews of research findings. It could be helpful to stakeholders seeking to promote awareness of current research and to increase the implementation and availability of evidence-based practices (EBPs). 18

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